A study found Google was more accurate than
the program’s physician directories.
By Austin Frakt July 8, 2019
If you try to use
Medicare Advantage, figuring out which doctors are available (and where) can be
exceedingly difficult, if not impossible.
Medicare Advantage is
the government-subsidized, private alternative to the traditional public
Medicare program. It has had strong enrollment growth for years.
That growth has received a boost from the Trump administration,
which has sent emails to people using Medicare to promote how much more
coverage they could get for less money from private plans. Missing from those
emails, however, is a mention of one big limitation of those plans: Many cover
far fewer doctors than the traditional program.
That may not be a
problem if you can find a plan that includes doctors you prefer, or if you can
find covered doctors in convenient locations.
But that isn’t often
the case, as government audits of
Medicare Advantage plan directories show. The Centers for Medicare and Medicaid
Services, which oversees the program, found that nearly half of entries had one
of three problems: address errors, incorrect phone numbers, or doctors who were
not accepting new patients. In 2017, the Department of Justice reached a settlement with
two Medicare Advantage plans over charges of misrepresentation of their
networks to regulators.
Other research
reveals that Medicare Advantage provider directories are relatively poor
sources of information. For example, a study published
in the American Journal of Managed Care found that Google was more accurate.
“Directory accuracy
is hard,” said the study’s lead author, Michael Adelberg, a former senior
Health and Human Services regulator in Washington and now a leader of health
care strategy for the Faegre Baker Daniels law firm. “But when a consumer joins
a plan to get to a doc in the directory and then cannot, that consumer has a
very legitimate beef.”
(I was a co-author on
the study, along with Daniel Polsky, a health economist with Johns Hopkins, and
Michelle Kitchman Strollo, a vice president and associate director of
NORC’s health care department at the University of Chicago.)
Not only is it
difficult for the average person to assess Medicare Advantage plan networks,
but it’s also hard for researchers. Nevertheless, a few things have been teased
out.
Working with plan
directories — flawed though they may be — a Kaiser Family Foundation
analysis examined the physician networks of almost 400 Medicare
Advantage plans offered by 55 insurers in 20 counties in 2015. It found that
networks of these plans included 46 percent of physicians in a county, on
average.
In other words, if
you selected a plan at random in these counties, you could expect that a bit
less than half of doctors would be covered, at least according to its
directory. (This does not necessarily mean those who are covered are taking
patients or practicing in locations convenient for you.)
The study found
considerable variation by specialty. Psychiatrists are least likely to be
included in plan networks; a typical plan covered fewer than one-quarter of
them. Ophthalmologist are most likely to be included; a typical plan covered
nearly 60 percent of them. Depending on what kind of care you need, the extent
to which plans cover specific specialists would be important to know. But there
is no single source that meaningfully compares Medicare Advantage plans’
networks in the aggregate, much less by specialty.
This could change.
A recent draft regulation would
require Medicare Advantage, as well as other kinds of plans, to provide their
directories in an electronic format that third parties could use to compare
them, for example through apps or online.
Why do plans’
networks vary anyway? One possibility is that plans may strategically narrow or
broaden their networks of certain specialties to try to attract more of the
kind of enrollees they want (healthier, cheaper) and fewer of those they don’t
(sicker, more expensive). Studies have shown that sicker beneficiaries are
less attracted to Medicare Advantage, perhaps for these reasons. Another
possibility, suggested by an Urban Institute study,
is that plans narrow networks to control productivity and quality — for
instance, covering only doctors who meet quality standards and tend to provide more
efficient and valuable care.
A study of Medicare Advantage plans offered in
California in 2017 found that the quality of obstetricians-gynecologists,
cardiologists and endocrinologists covered by those plans tended to be
comparable to those available through traditional Medicare. But some plan
enrollees, particularly those in more rural areas, would need to travel far —
in some cases exceeding 100 miles — to see those covered physicians.
The Kaiser Family
Foundation study found that broader-network plans tended to charge higher
premiums than “narrow network” plans (narrow network means covering less than
30 percent of doctors in a county).
One limitation of
analyzing plan directories is that even if physicians are listed as in-network,
they may not really be accessible because they’re too busy to accept new
patients. So another way to assess the influence of Medicare Advantage networks
on people’s access to care is to observe which doctors people in a specific
plan actually see.
Looking at it this
way, which colleagues and I did on a recent study published in
Health Affairs, reveals that 80 percent or more of Medicare Advantage
plans provide access to at least 70 percent of primary care physicians in their
markets. Our study also suggests that narrow network plans are not growing over
time in Medicare Advantage, which runs counter to the narrative that they’re
taking over health care.
Still, because there
is no way for Medicare beneficiaries to compare plan networks, people could
easily stumble into a narrow network plan without knowing it. As with many
things in health care, it’s hard to make an informed decision.
Austin Frakt is
director of the Partnered Evidence-Based Policy Resource Center at the V.A.
Boston Healthcare System; associate professor with Boston University’s School
of Public Health; and adjunct associate professor with the Harvard T.H. Chan
School of Public Health. He blogs at The
Incidental Economist. @afrakt
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